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Clinical Viewpoint: Social Work and Evolving Technologies

By Gary Stofle, ACSW, CASAC

This article discusses several issues surrounding the practice of psychotherapy online and is based upon a presentation at the NASW Conference in Baltimore, 1997. The author has conducted online psychotherapy sessions since December, 1996.

Current State of the Art

With the explosion of the Internet over the last several years, psychologists, psychiatrists, and social workers are beginning to provide helping services to clients online. While many therapists who provide services currently do so using e-mail to provide answers to questions people present to them, there are a growing number of therapists who provide online services in chat rooms with reportedly good results. However, other therapists are very firm in their belief that psychotherapy simply cannot occur online. The issues of competency, licensing, and practical considerations are briefly discussed below.

Competency

Competency in the provision of online psychotherapy is an area which causes ethical concerns for many therapists. Clearly, therapists should not practice in areas where they are not competent. It is felt therapists can be competent to provide online psychotherapy if they meet criteria in the following two areas: 1) experience, training, and expertise in providing traditional psychotherapy and 2) skills and abilities in online communication. The therapist needs to be grounded in a system of therapy that works to help clients develop insight, make changes, and grow.

This grounding comes through formal education, training, and actual experience in working with clients in an area of expertise and is vital to the success of online psychotherapy. Also, the therapist needs to have skills in typing, spelling, grammar, and online navigation. Even the most noted therapist could not provide online psychotherapy without these skills.

Licensing/Oversight

There is much debate and concern about therapists’ providing services to clients in other states or nations. Many view the provision of services as actually being done in the client’s state rather than the therapist’s state. There is concern about how the client can take legal action against the therapist if the therapist acts inappropriately. States are considering legislation to limit the provision of online services to the therapist’s state (e.g. California law now states that only therapists who are licensed in California can provide online services to residents of California). At this time New York has no such legislation (Editor’s Note: Neither does Massachusetts).

Practical Considerations

There are many practical considerations to providing therapy services online. The issues identified are obvious and are included in just about every article regarding the provision of services online: lack of nonverbal cues; starkness and potential coldness of text based communication; potential for misunderstanding; lack of control when the client is not in the room with the therapist; concern about the ability to establish a therapeutic relationship without seeing the client; and concern about whether or not the client is really who he says he is. All of these issues can and are being addressed by online therapists.

Summary

We can provide ongoing psychotherapy online. The characteristics of a competent psychotherapist - warmth, empathy, centeredness, honesty, genuineness - are expressed online just as they are in person. We use words, symbols, and timing to express these characteristics online, while in face-to-face therapy we use words, nonverbals, and actions to express them. It might be helpful to view online psychotherapy simply as another level of care - some clients/issues are appropriate for this level of care and others not.

When a therapist has competence in a particular area or with a particular population, that competence can translate directly to online work if the therapist possesses skills with typing and online navigation. The therapist adapts the treatment interventions to the modality, taking into account the lack of nonverbals. There are "nuts and bolts" issues that need further refinement, which will come from the practice. It is possible for a client to fake symptoms, or to pretend to be someone else. However, ongoing therapy is generally too hard to go through as a goof or gag and, if someone does, that indicates a different set of problems.

Many therapists are adopting a "wait and see" attitude towards the provision of online psychotherapy. If we proceed too cautiously in this journey because of the ethical issues, or decide not to provide online therapy services because of the unknown, who will be available to treat the clients who will not or are unable to seek face to face therapy?

If the ethical therapist is not online, who is?

This article was printed in the June 1999 edition of Update, the newsletter of the New York State Chapter of NASW. It is reprinted with the permission of the author.